2009 Thomas J. Watson Memorial Scholarship Application
(Complete and mail, postmarked no later than December 1, 2008.) Please type or print clearly. Information must be filled in exactly as you did on your
ACT or SAT Registration Form.
Last Name First Name Middle Initial Female Male
Number Street Apt. No. Area Code Telephone
City State Zip Code Country (if non-U.S. Resident)
Date of Birth * Parent’s IBM email address firstname.lastname@example.org
Month Day Year
*use alternate email address if IBM retiree, on approved leave of
absence, or receiving regular benefits under the IBM Medical
Disability Income Plan or Long-Term Disability Plan
Ethnicity/Group Identity (Please check the appropriate box)
Native American Asian African American Hispanic White (Non Hispanic) Multi-Racial Other
Note: If both parents are employed by IBM
please indicate in spaces provided. Employee Serial Number Employee Serial Number
Name of IBM Parent Name of IBM Parent
Home Address Home Address
IBM Division IBM Division
IBM Work Loc. Employment Date IBM Work Loc. Employment Date
Status: (Circle One) Active On Leave Retired Deceased Status: (Circle One) Active On Leave Retired Deceased
+Contact IBM +Contact IBM
Relationship: (Circle One) Parent +Stepparent +Other Relationship: (Circle One) Parent +Stepparent +Other
to verify eligibility to verify eligibility
ACT and SAT Information
I understand that it is my responsibility, when completing the score report section of my ACT or SAT Registration Form, to enter Code
Number 9928 (Watson Scholarship Program) as one of the colleges or scholarship programs to which my scores are to be released.
The last admissible ACT is October 25, 2008 and the last admissible SAT is November 1, 2008. If I have already registered for or
taken the ACT or SAT and did not specify Code 9928 as a score recipient, it is my responsibility to file an Additional Report Request
Form with the College Board ACT no later than October 31, 2008 or SAT no later than November 7, 2008 and specify Code 9928.
Scores may be reported directly on the Watson application by the school official who submits the application to SRP. I understand that
the decision of Scholarship and Recognition Programs of Princeton, NJ, will be final in the selection of Watson Scholarship
winners and in the determination of student funds, related to individual need, which accompany the scholarship.
I certify that the information above and submitted with this application is accurate.
I authorize release of any information relating to this application to IBM, its administrators for this program, or their representatives, as necessary to
review the application. I agree that IBM’s administrators for this program may release to IBM, or any administrator designated by IBM, upon IBM’s
request, any records and information in its possession in connection with this application. A photostatic copy of this authorization shall be as effective as
the original. I understand that if I file or authorize another to file an application knowing that it contains false, deceptive or misleading information or a
deceptive or misleading omission, then I may be subject to dismissal, loss of eligibility under the plan and/or criminal prosecution.
Applicant’s Signature (Please use exact name, including
Jr., II, apostrophes and hyphens) Date
Parent’s Signature (IBM employee’s) if student is under 18 Date
Note: You will receive an acknowledgment email from SRP confirming receipt of your application. If you do not receive this
email by December 15, 2008, please call SRP at (609) 771-7878.
See Page 2 for secondary school information.
Secondary School Information (to be completed by the Principal, Headmaster or Guidance Counselor.) All questions must be completed.
Name of Secondary School School Code No.
Number and Street
City State Zip Code
Is the student now a senior in high school? Yes No Graduation Date
If not, please explain
Exact Rank in class in Junior Year Junior Class Size
ACT test date: Composite Score: SAT test date: Writing: Critical Reasoning: Math:
Name of Principal, Headmaster or Guidance Counselor (Please Print and Circle Title) Signature Date
Important to Secondary School Official: Mail this completed application to Thomas J. Watson Memorial Scholarship Program, Scholarship and
Recognition Programs, Educational Testing Service, P.O. Box 6730, Princeton, NJ 08541, postmarked no later than December 1, 2008.